Educational Assistance Application

Instructions:

• Complete the educational assistance application and attach descriptive information regarding the course(s) or degree program you wish to enter.  
• Meet with your department manager to discuss your educational assistance request. If it is agreed that your request meets policy guidelines and budgetary restrictions, the manager will grant preliminary approval.
• Submit the original, signed form to the human resources (HR) department for final review.
• If funding is approved, a check for one-half of your tuition and fees will be advanced to you.
• Upon completion of the course, submit a copy of your grade report to the HR department. If the course was successfully completed the other ½ of your tuition will be reimbursed to you. If the course is not successfully completed, payback of the advanced tuition will be arranged.

Total cost $__________

Development objective (what long-term goal is this program/course intended to help you reach):

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

If seeking a degree program, please attach a brief outline of the courses included in the program from the college catalog or program brochure (necessary for initial request only).

I understand that if this request is approved, reimbursement will be contingent upon successful completion (a grade of B or better for graduate courses; a grade of C or better for undergraduate courses) of each course and submission of all receipts and paid bills within 30 days thereafter. I further understand that failure to successfully complete any course(s) will result in an obligation to repay [company name] the amount of tuition advanced.  

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Employee Signature

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Date 

[  ] Approved                [  ] Not approved 

Reason: ________________________________________________________________

_______________________________________________________________________

Does this application meet the established guidelines of the educational assistance program policy?  [  ] Yes     [  ] No

Was this expense included in the department budget?

 [  ] Yes     [  ] No

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Department manager signature

___________________________________
Date 

This request is       [  ] Approved         [  ] Not approved 

Reason (if not approved): _____________________________________________________

_________________________________________________________________________

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Human resources manager signature

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Date

Date:       ___________________________

Advance in the amount of $ ________________ is approved.

Expense should be charged to ________________________________________

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Accounting manager signature

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Date

Date:  __________________________

Reimbursement in the amount of $ _______________________ is approved.

Expenses should be charged to: ____________________________________

Documentation of successful completion attached:   [  ] Yes    [  ] No

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Accounting manager signature

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Date